Existing hospitals’ journey into a sustainable and climate-resilient future: barriers and opportunities for estates and facilities management Open Access

Climate change is leading to more intense heatwaves, increased flooding and storm risks and shifts in emerging infectious diseases, which threaten the health system’s capacity to protect and promote people’s health, potentially reversing decades of public health progress (Mosadeghrad et al., 2023). Health-care systems are on the frontline in dealing with climate-induced demand for health care (Braithwaite et al., 2024; Salas and Solomon, 2019); however, they also contribute to the problem, generating carbon emissions that account for 4.4% of the global net (Karliner et al., 2020). The actions needed to manage the complex environmental and societal costs of delivering health services are substantial (Braithwaite et al., 2024). Hospitals are energy-intensive facilities that consume large amounts of water and generate polluting emissions and health-care waste, contributing to climate change (Sahamir and Zakaria, 2014). They use nearly twice as much energy per square meter as other office buildings, underscoring their high consumption rates (Mashallahi et al., 2022). Therefore, hospitals must take necessary actions to minimise greenhouse gas emissions to comply with the United Nations Climate Change Conference (COP21) (United Nations Framework Convention on Climate Change, 2015). Conversely, the increasing frequency and severity of climate-induced hazards (Jetten et al., 2021) can significantly impact hospitals (Carthey et al., 2009), damaging facilities, compromising patient safety, causing equipment failures and leading to higher service demand (World Health Organization, Regional Office for Europe, 2009; Carmichael et al., 2013; Achour et al., 2015; Kovats and Brisley, 2021). Health-care systems thus face a challenge: they must maintain high-quality care while ensuring climate resilience by adapting to rising climate-induced threats, all while mitigating their significant contributions to the climate crisis. In 2022, the National Health Service (NHS) became the first health system to incorporate net-zero principles into legislation through the Health and Care Act 2022 (Department of Health and Social Care, 2022). This act outlines a strategy with two targets to address climate challenges: achieving net-zero emissions by 2040 for the emissions directly controlled by the NHS and reaching net-zero by 2045 for emissions the NHS can influence. In addition, following the 2008 Climate Change Act, NHS England and other health-care entities must adapt to climate change impacts. These documents acknowledge the NHS estates and facilities as vital for addressing the effects of health care on climate change. In addition, current hospitals were not designed to withstand climate-related threats, highlighting the urgent need for strategies that ensure their functionality during extreme weather events (Carthey et al., 2009). Estates and Facilities Management (EFM) professionals play a crucial role in the operation and maintenance of buildings, ensuring that intended service outcomes are achieved (Rameezdeen et al., 2019). They have the potential to develop solutions and positively contribute at both organisational and societal levels (Nielsen et al., 2016). However, several barriers hinder their ability to achieve sustainability in EFM, including limitations in capability, knowledge, organisation and authority, with a significant lack of support from senior management (Sarpin et al., 2016; Elmualim et al., 2008). Støre-Valen et al. (2014) examined the challenges faced by EFM professionals in managing health-care estate, focusing on issues such as maintenance, adaptability, communication, training, long-term planning and the need for a proactive approach to hospital development. However, Sarpin et al. (2016) emphasised that there is a need for greater attention to be given to integrating sustainability into the operation and maintenance phase of EFM practices. Therefore, this paper aims to identify barriers and opportunities hospital EFM professionals encounter in the journey towards creating a future sustainable and climate-resilient hospital estate.

The NHS in England aims for a net-zero carbon status due to climate change health threats, as outlined in the Health and Care Act 2022 (Department of Health and Social Care, 2022). To achieve this, the NHS published the “Delivering a ‘Net Zero’ National Health Service” (NHS England and NHS Improvement, 2020), which outlines the NHS’s carbon footprint and pathways to net zero. In 2022, NHS England also published the NHS Net Zero Building Standard (NHS England, 2023c), which provides a roadmap for reducing operational building energy demands, embodied carbon in construction and the whole-life carbon of building elements used within them, primarily focusing on new buildings rather than refurbishment of existing ones (Amamou et al., 2025). The Health and Care Act 2022 mandates NHS trusts to create Green Plans outlining essential actions for reducing emissions and enhancing resilience to climate impacts over the next three years (NHS England, 2025). The guidance for creating Green Plans requires trusts to establish Specific, Measurable, Achievable, Relevant and Time-bound (SMART) targets and corresponding key performance indicators (KPIs) for each focus area. However, an analysis conducted by Amamou et al. (2025) on 181 publicly available Green Plans revealed that KPIs were mentioned in only 11% of these plans. Furthermore, only five trusts provided specific, measurable and time-bound values for their KPIs, and only one trust reported having developed SMART objectives. Following the 2008 Climate Change Act, NHS trusts are required to adapt to the impacts of climate change. However, the current approach of the NHS primarily focuses on mitigation strategies intended to reduce the environmental impact of NHS facilities. Therefore, there is a lack of emphasis on adaptation strategies, essential for reducing vulnerability and risks associated with climate change and strengthening resilience (Elstow et al., 2024). Furthermore, lengthy approval processes for standard operating procedures mean that official guidance, such as “Health Technical Memoranda”, is updated only every 5–10 years, leading to fragmented and often outdated knowledge found in various documents (Von Behr and Minshall, 2022).

The UK Government supports the decarbonisation of the public sector through targeted grants. A significant initiative is the Public Sector Decarbonisation Fund, which focuses on upgrading energy efficiency and installing low-carbon heating systems. Additionally, Salix Finance offers interest-free loans to public sector organisations for energy efficiency projects (Department for Energy Security and Net Zero, 2020). Another programme, the Low Carbon Skills Fund 2020, helps eligible public sector bodies hire specialists to identify and develop energy efficiency and low-carbon heating upgrade projects for non-domestic buildings (Department for Energy Security and Net Zero and Department for Business, Energy and Industrial Strategy, 2024). Since 2020, over 1,000 projects have received funding, with £557m allocated to upgrade public buildings’ heating systems and improve energy efficiency (Public Sector Experts, 2025). While these funds offer NHS trusts the opportunity to reduce their carbon emissions, they are part of a capital investment strategy that has undergone significant changes over the past 15 years, with a growing portion of capital budgets redirected to cover day-to-day operating expenses, resulting in the deterioration of NHS buildings and equipment (King’s Fund, 2024). However, in 2019, the Department of Health and Social Care launched the Health Infrastructure Plan, a five-year initiative to improve health infrastructure by building new hospitals, modernising primary care and advancing technology (Department of Health and Social Care, 2019) and the 2021 Spending Review allocated funding to support the New Hospitals Programme, enhance diagnostics and invest in mental health, while contributing to the NHS’s “Net Zero” strategy. This aligns with the current shift from hospital-centred care to community-based care (Department of Health and Social Care, 2024), which can reduce demand for acute care and supports a fully integrated care model, leading to smaller, hybrid hospitals focused on emergency and specialist care, with the role of “Control Towers for the Community” (Pascale and Achour, 2024).

In 2023, NHS England released the “Capital investment and property business case approval guidance” to assist NHS trusts with capital investment approvals. The guidance aims to improve infrastructure, balance autonomy with governance, ensure value for money, clarify approval processes and streamline business case approvals for better patient outcomes (NHS England, 2023a). At the same time, NHS England has implemented new requirements for trusts that exceed their budgets [Healthcare Financial Management Association (HFMA), 2022]. A double-lock sign-off process is required for revenue investments exceeding £50,000, which involves approvals from the provider and the Integrated Care Board. A triple-lock sign-off process is necessary for revenue investments above £100,000, requiring approvals from the organisation, the system and the NHS England regional team.

The NHS estate and its associated facilities represent 19% of the overall carbon emissions profile (NHS Sustainable Development Unit, 2012). Simultaneously, these facilities face significant vulnerabilities to climate-related risks; specifically, 7% of all hospitals in England are located in areas identified as high flood risk, whereas 90% of hospital wards across the UK are susceptible to the dangers of overheating (Environment Agency, 2009; Short et al., 2014). Recent research has identified various strategies hospitals can implement to optimise energy use and adopt a more sustainable approach (Tomanek, 2024). These strategies include conducting energy audits, renovating building designs, optimising lighting, upgrading equipment, implementing energy management systems, integrating renewable energy sources, providing staff training, enhancing heating, ventilation, and air conditioning (HVAC) efficiency, monitoring performance and fostering collaborations and partnerships. Silva et al. (2024) also conducted comprehensive research on improving energy efficiency in health-care buildings. They proposed passive and active design and renovation measures to create energy-efficient and comfortable health-care environments. Their findings suggest that retrofitting existing buildings with improved insulation, upgraded windows and green roofs could save up to 89% of energy. Conversely, the available literature on climate adaptation actions for health-care facilities is limited (Elstow et al., 2024). A recent systematic review of climate-adaptive hospitals identified only 26 relevant documents from an initial pool of 11,680 published studies (Mashallahi et al., 2022). This highlights that the primary focus is still on surge capacity to manage an influx of patients resulting from climate change-related events, which aligns with the WHO guidelines for climate-resilient and environmentally sustainable health-care facilities [World Health Organization (WHO), 2020].

Implementing mitigation strategies in the health-care sector should begin with conducting energy audits to identify areas of energy waste and inefficiencies. Appointing a dedicated energy manager within hospital facilities is also essential (Bevere and Faccilongo, 2024). In this context, Building Energy Management Systems (BEMS) play a key role by integrating energy data from various sources within the hospital into a centralised platform. This enables real-time monitoring and control of energy consumption, allowing EFM professionals to identify inefficiencies and implement targeted energy-saving measures (Bevere and Faccilongo, 2024; Silva et al., 2024). In addition, Wanigarathna et al. (2019) highlighted that Building Information Modelling (BIM) can improve hospital estate management by providing insights into the physical condition of the facilities and their impact on health-care delivery. However, successful implementation of BIM requires interdepartmental information sharing, which can involve significant investments in time, costs and changes in information practices throughout the organisation. Climate resilience assessments are essential for identifying areas for improvement and prioritising interventions (Heinimann and Hatfield, 2017). The role of EFM professionals in managing risks and developing Business Continuity Plans (BCPs) related to climate change is crucial; however, this topic is not extensively covered in the literature (Warren, 2010). Tools like the Hospital Safety Index (HSI) assist this process [World Health Organization (WHO), 2015]. Nevertheless, the HSI’s methodology does not adequately address the impact of climate change on disaster risks, which is vital for evaluating the resilience of buildings (Nenković-Riznić et al., 2018). Furthermore, while other tools exist to assess climate change and health vulnerability, they typically focus on improving disaster management phases rather than supporting long-term planning (Balbus et al., 2016).

Addressing the need for mitigation and adaptation in NHS infrastructure is complex due to the numerous NHS buildings and the poor condition of many health-care facilities. In 2022, there was a maintenance backlog of £10.2bn, which marked an 11% increase since the previous year (NHS Digital, 2023), and much of the existing health-care estate is outdated and underused (Achour, 2020; King’s Fund, 2013). In their roadmap for creating resilient and sustainable health-care facilities, Pantzartzis et al. (2019) identified backlog maintenance as a significant challenge in managing the NHS hospital estate. They linked this issue to various factors, including understanding trust assets, the condition of ageing buildings, investment strategies and performance metrics. In addition, recent research on the knowledge-sharing barriers encountered by EFM in the NHS during the journey towards sustainable and resilient healthcare identified four primary organisational context barriers (Von Behr and Minshall, 2022). The fragmentation of the health-care system presents a significant challenge, as different trusts often operate in isolation. In addition, variations in ownership and service contracting models, such as Private Finance Initiatives (PFI), complicate matters due to limited control over buildings and the extra costs incurred while trying to achieve sustainability goals. Furthermore, outsourcing some or all EFM services to external contractors can lead to the loss of knowledge within the estate departments. Finally, the political dynamics within EFM departments differ across various trusts. Since estate directors do not serve on all trust boards, there are inconsistent levels of autonomy and support for EFM, which can result in budget conflicts between the estate and medical departments (Von Behr and Minshall, 2022). According to Rodriguez-Labajos et al. (2017), clinical services are often prioritised in healthcare, which can neglect estates and facilities. This situation limits EFM professionals’ ability to effectively manage their resources while holding them accountable for operational planning. Previous research has recognised the importance of health-care managers valuing the role of EFM in health-care delivery rather than viewing it solely as a cost centre, given the hospital’s EFM as part of sustainable resource management to improve health-care outcomes (Amos et al., 2021). However, to be able to face the challenges of transitioning to a sustainable and climate-resilient estate, EFM professionals need to be technically qualified and understand intelligent building complexities (Finch and Clements‐Croome, 1997) and embrace a sustainable practice that integrates social, environmental and economic aspects through a culturally embedded understanding (Galamba and Nielsen, 2016).

EFM professionals encounter challenges in navigating the complexities of sustainability and making informed decisions (‌Støre-Valen and Buser, 2018), especially when there is a lack of clarity surrounding the sustainability goals (Galamba and Nielsen, 2016). In the UK, hospitals adhere to the guidance provided by the Royal Institution of Chartered Surveyors (RICS) (2021) regarding strategic estate management. This management approach aligns the property estate with the organisation’s goals to create financial and non-financial value. To achieve this, hospitals must establish clear strategic goals that outline their direction and express these in a way that enables EFM professionals to assess how well the physical, human, financial, cultural and informational processes and systems of the current estate can meet these strategic goals and add value to the organisation. When making such assessments, facilities managers need to anticipate the impact that change drivers, such as sustainability and climate resilience (Pascale and Jones, 2023), will have on performance levels throughout the estate life cycle. They should also develop interventions that can be implemented over time to manage these changes effectively. Desai and Jones (2010) argued that whilst the aforementioned approach is consistent with global best practices, several practical issues are associated with translating the strategic approach into a set of operational tools. In addition, EFM professionals have no well-defined process to prepare effective strategic management plans to make their facilities climate-resilient (Warren, 2010). Therefore, Desai and Jones (2010) contend that institutional memory often keeps organisations tied to past interventions, hampering radical thinking needed for addressing climate change. To overcome this, Jones et al. (2015) suggested that facilities managers adopt a backcasting approach instead of forecasting. By setting future performance goals and evaluating maintenance plans by looking back on these goals, organisations can minimise the impact of current trajectories and enhance their chances of achieving desired outcomes. However, implementing future-based studies, such as backcasting, with technical stakeholders presents challenges. These stakeholders often struggle to envision a trajectory that moves backwards from the future, and the urgency of the transition they perceive can lead them to focus solely on immediate tasks, overlooking longer-term planning (Lundgren et al., 2024).

This paper presents the results of two half-day workshops, organised as part of a research project, which aims to develop a framework to provide hospitals with integrated mitigation strategies to transition to a zero-carbon future by 2050 and adaptation strategies to address existing climate change through better-informed facilities and built asset management planning. The research employs a participatory backcasting research methodology, with an NHS trust in southeast England as a case study. This methodology was selected as it can facilitate essential changes in estate management to address future climate change (Jones et al., 2015) by developing a desirable future vision and then outlining pathways to achieve it with stakeholder involvement (Quist and Vergragt, 2006). This research follows the participatory backcasting process developed by Quist and Vergragt (2006), which involves five steps adapted by Jones et al. (2015) in the case of built asset management, as represented in Figure 1.

In the project’s first step, a scoping study was completed to identify the driving changes for the hospital of the future, and strategies implemented or auspicated within these areas for the past 20 years have been identified and evaluated (Pascale and Jones, 2023). The research results presented in this paper are based on the activities undertaken to construct a vision of the future hospital and its operational scenarios. This research step developed a holistic vision of a sustainable and climate-resilient hospital in 2050, featuring 14 aspirational targets, as reported by Pascale and Achour (2024). This vision was developed based on the results of a workshop undertaken with a wide range of stakeholders working for or involved with the NHS trust case study, considering the impacts of climate change in the region and potential progress in addressing climate change, using the UK Climate Resilience Programme’s scenarios, known as shared socio-economic pathways (UK Centre for Ecology and Hydrology, 2024), to provide participants with a broader context (Pascale and Achour, 2024). This paper presents the results of the two half-day workshops aimed at translating the holistic vision of the sustainable and climate-resilient hospital in 2050 presented in Pascale and Achour (2024) into operational scenarios for an existing hospital estate and identifying barriers and opportunities for achieving that vision. A multidisciplinary team of 14 participants, identified by engaging with the NHS trust case study, research and academia, contributed to the workshops (see Table 1). During the first workshop, participants engaged in activities that encouraged discussion on the relevance of the aspirational targets concerning the journey of existing hospitals to become more sustainable and resilient to climate change, the hospital’s current and future performance relative to the aspirational targets, and the barriers existing hospitals face to achieving the vision of the hospital of the future. During the second workshop, participants engaged in activities to turn the aspirational targets into SMART objectives that align with the hospital’s vision. The participants collaborated in interdisciplinary groups, using flipcharts and Post-it notes to organise their ideas, while their conversations during the activities were recorded. During the workshops, although the research team had specific activities planned, the discussions among participants primarily centred on the barriers faced by hospital EFM professionals in pursuing a sustainable and climate-resilient hospital estate. This emphasised the need to closely examine and address these barriers to encourage progress towards a sustainable, climate-resilient hospital estate. A thematic analysis using the six-phase analytical process supported by NVivo version 14 (Braun and Clarke, 2012; Nowell et al., 2017) was conducted to analyse the results of the two workshops. A preliminary data cleaning process and script preparation were conducted to ensure the data was ready for analysis. The researchers then began with an in-depth exploration of each data set, focusing on identifying barriers and opportunities. Codes were generated inductively, and weekly meetings were held for peer debriefing during the coding process. After identifying the themes, the team reviewed the coded data extracts for each sub-theme to find coherent patterns. This approach led to comprehensive analyses of each theme, clarifying their interrelations within the context of the research questions. Discussions confirmed that the themes were consistently represented across all cases, enhancing the validity of the findings.

During the workshops, participants identified several barriers that prevent existing hospitals from achieving the vision of a future sustainable and climate-resilient hospital. These barriers were grouped into estate management, financial aspects and NHS organisational development. These are explained in the sections below and summarised in Table 2.

Planning: Within the overall estate management strategy, barriers were associated with implementing the short-term, fragmented and reactionary approach, exacerbated by the lack of central and government support in strategic planning:

According to the participants, clinical services are changing at a fast pace; however, the hospital estate is not changing quickly enough to accommodate these changes, which may require it to become more dispersed and integrated with the community health-care estate. While weaker approaches to planning were reported as a barrier, long-term clinical strategies were seen as an opportunity for long-term estate planning. Integrated care delivery was also seen as an opportunity to free up hospital space and allow planning for reconfiguration. Furthermore, current carbon assessments were defined as generic to support planning effectively. Consequently, current strategies adopted in the journey to net-zero and climate resilience were considered fragmented and staggered.

Targets and KPIs: The lack of long-term SMART targets or KPIs to lead effective estate management strategies was seen as a barrier. Existing strategies, like Green Plans, often offer too generic and broad targets. In addition, the fact that the Net-zero targets were established against the 1900 baseline has created a superfluous industry of specialists in developing baselines, which does not provide added value to achieve net-zero goals – problems in understanding carbon footprint as a target were seen as a barrier.

Knowledge of the estate: To implement effective upgrading strategies towards mitigation and adaptation, a detailed assessment of the existing estate is essential. This assessment should include identifying vulnerable areas throughout the hospital estate, implementing a BEMS and using sensors to monitor the temperature in the most susceptible areas, as the lack of vulnerability assessment was seen as a barrier to improving climate resilience. Furthermore, the absence of digital models of the estate, both in 2D and 3D formats and the lack of a BEMS, was identified as a barrier to comprehending the estate. In addition, the unavailability of a central repository for estate information contributes to fragmentation and raises the risk of losing valuable information when individuals leave the hospital.

Maintenance strategies: The barriers identified in the current maintenance strategy were associated with:

• a lack of preventative maintenance strategy in hospitals;

• the current maintenance backlog;

• the increased complexity of the technology implemented within the estate; and

• the current approach to compiling the risk register that does not allow for prioritising and funding interventions appropriately.

Computer-Aided Facilities Management (CAFM) systems were seen as an opportunity to organise and coordinate maintenance interventions, while having a maintenance strategy allows improvement in the transition journey, as when interventions are planned, the backlog can be tackled simultaneously.

Net-zero estate: There was a view that existing hospitals would never get to net-zero carbon without significant offsetting because of the constraints due to their footprint:

This was mainly due to issues related to power generation. While some participants believed that hospitals could use their roofs to install renewable energy sources for power generation in the future, others suggested solutions, such as acquiring brownfield sites to deploy large-scale solar farms directly connected to the hospitals’ sites. In addition, the lack of updated standards to support the net-zero transitions and the capacity of the electrical grid were described as barriers in the journey towards net-zero. The need to employ an energy manager to support the planning and coordinate the activities emerged.

Climate adaptation of the estate: The absence of long-term adaptation strategies for the estate was identified as a significant barrier. Participants acknowledged that adapting the current estate to future climate conditions and temperatures would be very challenging unless strategies for repurposing and disposal were considered. While there is an understanding of hospitals’ climate-induced risks, as these are typically listed in the risk register, this understanding rarely translates into comprehensive risk assessments, identifying vulnerabilities and proposing adaptation strategies to enhance climate resilience. The current overheating strategy was described as reactionary and did not involve long-term intervention on the estate. The risk of flooding was known; however, little is understood about possible adaptation strategies. The simplification of the BCP was seen as an opportunity to improve the estate’s resilience. Also, understanding the changes in the external climate was described as an opportunity to plan well ahead and save money in the long run, while monitoring the existing estate through sensors was suggested as a suitable strategy to understand vulnerabilities to overheating.

Suitability for retrofit: The unsustainability of the existing estate in terms of footprint and building typologies, such as the predominant use of multistory buildings, the high complexity and the quality of the buildings and the environment, was described as the main barrier to retrofitting and upgrading the existing estate. Additional barriers were associated with ageing buildings, fabric, structure and utility systems that can no longer meet the ever-changing demand. In addition, the lack of updated standards to support the net-zero transitions, alongside the capacity of the electrical grid, was described as an external barrier in the journey towards retrofitting and upgrading the existing estate to achieve net-zero. Integrated care delivery and digital technology were opportunities to reduce the demand for physical assets, optimise infrastructure use and focus budgets on critical improvements.

Funding availability: Budget and funding mechanisms were defined as significant barriers to achieving the hospital’s future vision:

In the current financial climate, the funding required to upgrade the estate was considered substantial and reliant on political support decisions. Available funding was deemed sufficient only for minor and urgent issues, while the funds required to upgrade the entire estate were considered unavailable. This lack of funds negatively impacts the establishment of clear targets for the estate.

Funding Sources: Reliance on capital investment grants generates high uncertainty, which does not support long-term planning and creates an administrative burden. The private finance initiative (PFI) was seen as an opportunity to introduce innovation within the asset. However, an effective contractual strategy is required.

Investment appraisal strategies: Business cases were described as solely accounting for the initial capital because of the lack of funds. This primarily affects the ability to maintain the asset appropriately. Secondly, looking only at the initial capital does not allow for consideration of resource-related issues, such as staff availability, and for showing the benefits of the costs that could be discounted because of long-term savings:

The system’s inability to consider revenue is also due to the lengthy process of approving a business case. This extended timeline often means that the business case becomes outdated by the time it is put into action, rendering initial plans obsolete. There was an agreement that integrating initial capital revenue, the life cycle model and climate resilience in the business case would be more expensive upfront but save money in the long term. Considering energy cost analysis could support demonstrating that the payback on the investment can be shorter than expected.

Procurement: The procurement process was viewed as a hindrance to realising the future hospital’s vision, as it significantly limits what the trust is attempting to accomplish. The double- and triple-lock approval procedures for revenue investments have further increased the burden of the process. In addition, suppliers with sustainable credentials (e.g. green energy suppliers) are still not prioritised because of the higher costs.

Contracts and agreements: NHS trusts cannot enter into power purchase agreements or energy performance contracts due to the lease length involved and its impact on the available capital. Therefore, strategies for offsetting, such as solar farming, which can be directly wired and cabled back to the hospital, feeding directly into the hospital’s electrical infrastructure, are not available avenues for NHS trusts.

Hospital leadership: Leadership was considered essential to driving the changes; however, the short-term planning approach and the current focus on decreasing expenditures hindered this effort. Hospital leadership’s dependency on government policies was also seen as a barrier. Changing the leadership culture was seen as essential to moving the transformation forward. There was widespread dissatisfaction that funding is prioritised for clinical services over estates and facilities, stemming from a lack of understanding that the estate cannot accommodate the demands of evolving clinical services without investment in physical assets. However, long-term clinical strategies were seen as a way to change the approach and introduce long-term planning.

System leadership: There was apparent discomfort with the government and the NHS’s setting net-zero targets without providing the right resources to achieve them. It was discussed that changes would have been possible with a shift from hospital to system leadership. Creating a network of hospital Chief Executive Officers (CEOs) could drive the political agenda.

Role of FM in the leadership structure: There was also a strong sense of disconnection between the needs emerging from the running of the estate and the leadership’s priorities. The lack of strategic representation of the EFM team was also seen as a barrier: “I think the problem is we are not privy to the conversations that are being had at that level” (Workshop Participant). In addition, the sustainability teams were described as not “having enough voice in the trust” (Workshop Participant). Better integrating the sustainability teams with the leadership structure was seen as an opportunity to drive the sustainability agenda.

Upskilling in EFM: Enhancing the skills of hospital EFM professionals was described as crucial, as it will better equip them to navigate the growing influence of technology in the industry. This requires focused training programmes and a generational shift to attract more tech-savvy EFM employees. However, EFM was described as an unappealing profession for younger generations, especially in the NHS.

Recruitment: Recruitment into the NHS EFM was considered a barrier. This is because other competitors can offer better salaries and progression options. Recruitment challenges compel trust to depend on external contractors, hindering the organisation’s ability to retain expertise. These were suggestions that this could be improved with a pay scale reform for EFM professionals in NHS, with regionalised salaries reflecting the demand in the area.

Cultural difference: There seems to be divergent priorities between clinicians wanting the latest technologies and not understanding the need for infrastructure to accommodate them. In addition, the need to move services within the community to reduce the impact of the hospital infrastructure and free space for the needed interventions was critical for the EFM team but not shared by the clinical teams, who are reluctant to explore new ways to deliver services and eventually move to community settings.

Climate change is causing more extreme weather events and health risks, threatening public health and reversing health-care gains (Mosadeghrad et al., 2023). Health-care systems are at the forefront of this crisis (Braithwaite et al., 2024) and contribute to it due to their energy use and waste generation (Sahamir and Zakaria, 2014). The increasing frequency of climate-related hazards (Jetten et al., 2021) also affects health-care systems (Carthey et al., 2009). In 2022, the NHS became the first health system to embed net-zero principles into legislation, aiming for net-zero emissions by 2040 (Department of Health and Social Care, 2022). Following the 2008 Climate Change Act, NHS England and other health-care entities must adapt to climate change impacts. To achieve net-zero targets, the NHS in England published “Delivering a Net Zero National Health Service” (NHS England and NHS Improvement, 2020), which outlines the NHS’s carbon footprint and pathways to net zero, emphasising the role of estate and facilities. However, EFM professionals face barriers to achieving sustainability (Sarpin et al., 2016; Elmualim et al., 2008). This paper identifies barriers and opportunities hospital EFM professionals encounter in the journey towards creating a future sustainable and climate-resilient hospital estate, organised into three main themes: estate management, financial aspects and NHS organisational development.

Hospitals are strategic infrastructures, and their estate management should align with the organisation’s goals, providing financial and non-financial value (RICS, 2021). However, the current estate management strategy used by NHS hospital trusts is short-term, fragmented and reactionary, consistent with findings by Støre-Valen et al. (2014) and a lack of central government support for strategic planning worsens this situation. The NHS has produced guidelines, such as the “Delivering a ‘Net Zero’ National Health Service” report (NHS England and NHS Improvement, 2020), detailing the NHS’s carbon footprint, trajectories to net zero, and required interventions. The NHS Net Zero Building Standard (NHS England, 2023c) instead provides a roadmap for reducing operational building energy demands, embodied carbon in construction, and the whole-life carbon of building elements, but it falls short in providing operational support for existing hospital buildings (Amamou et al., 2025). The NHS should establish mechanisms to support EFM to consider how interventions to achieve net-zero can also address changes in the external climate and the fast-paced changes happening in health-care delivery (Pascale and Achour, 2024) and translated into technical guidance, such as “Health Technical Memoranda” (Von Behr and Minshall, 2022). At the trust level, understanding the role of hospitals in the future integrated and technology-driven care delivery system and developing a 10-year clinical strategy presents an opportunity to define future goals. However, hospital EFM professionals find it challenging to clearly define their strategic goals due to biases arising from long-standing barriers identified by current research. This adds to the reliance on institutional memory, as Jones et al. (2015) noted, which limits their ability to adapt to future demands. To address this, hospital EFM professionals should adopt future-based approaches, such as backcasting, in estate management. Setting future performance goals and evaluating past progress makes it possible to move beyond existing maintenance and refurbishment plans, as Jones et al. (2015) argued. Future scenarios should be developed based on future climate scenarios, the long-term clinical plan and anticipated changes in the broader health-care system to overcome these challenges. To support this process, the NHS should provide clear and relatable metrics regarding decarbonisation and climate resilience, to support trusts’ ability to define SMART targets and associated KPIs (Amamou et al., 2025). In addition, a thorough assessment of the existing estate is essential for implementing effective upgrading strategies for mitigation and adaptation, as also identified by Pantzartzis et al. (2019). This is currently hindered by the absence of digital models of the estate, which can enhance decision-making in health-care asset management by integrating data on asset conditions and resources (Wanigarathna et al., 2019), and the absence of BEMSs, which can support EFM professionals to identify areas of inefficiency and implement targeted energy-saving measures (Bevere and Faccilongo, 2024; Silva et al., 2024). The lack of vulnerability assessment was considered a barrier from an adaptation perspective. This is due to the limited awareness of how climate change-induced events affect health services (Heinimann and Hatfield, 2017; Carthey et al., 2009). Moreover, the available tools to evaluate hospital resilience either fail to address the impact of climate change on disaster risks, which is crucial for assessing the resilience of buildings (Nenković-Riznić et al., 2018), or they tend to prioritise improving disaster management instead of supporting long-term planning (Balbus et al., 2016). Monitoring the existing estate with sensors can help identify vulnerabilities and inform a clear BCP, thereby improving the estate’s resilience.

The NHS guidelines provide a roadmap and mitigation strategies for achieving net-zero, while academic literature outlines approaches hospitals can adopt to optimise energy use and embrace sustainability (Tomanek, 2024). In addition, it presents effective examples of passive and active retrofitting measures that promote energy-efficient and comfortable health-care buildings (Silva et al., 2024). However, research participants expressed scepticism about the capability of existing hospitals to meet net-zero targets without significant offsetting due to the limitations of the estate footprint. From an adaptation perspective, participants acknowledged that adapting the current estate to future climate conditions and temperatures is challenging unless strategies for repurposing and disposal are considered. This can be attributed to the fact that hospitals were not initially designed to account for climate-related risks (Carthey et al., 2009), and the available literature concerning climate adaptation actions for health-care estate is limited (Elstow et al., 2024). However, a limited connection between risk assessments, vulnerabilities and the proposal of adaptation strategies to enhance climate resilience has also emerged. The role of EFM professionals in managing risks and developing BCP related to climate change impacts on the estate is vital. However, EFM professionals lack a process to integrate climate resilience into effective strategic management plans for the estate (Warren, 2010). In addition, EFM professionals need to implement these within an estate defined as unsustainable, complex and unable to meet ever-changing demands. The NHS manages an extensive building stock (NHS England, 2023a, 2023b, 2023c; Short et al., 2014) that is underused and outdated (Achour, 2020; King’s Fund, 2013), with a £10.2bn maintenance backlog as of 2022 and an 11% increase since 2022 (NHS Digital, 2023). Ageing buildings have also been identified as contributing factors to the backlog maintenance and risks NHS hospital trusts face in the roadmap to resilient and sustainable health-care facilities, developed by Pantzartzis et al. (2019). However, in contrast to Pantzartzis et al. (2019), research participants identified the transition to a sustainable and climate-resilient estate as an opportunity to address backlog maintenance.

Budget and funding mechanisms are significant barriers to transitioning to a sustainable and climate-resilient estate. Although the government has allocated funds to support the decarbonisation of the public sector – such as the Public Sector Decarbonisation Fund, Salix Finance (Department for Energy Security and Net Zero, 2020) and the Low Carbon Skills Fund (Department for Energy Security and Net Zero and Department for Business, Energy and Industrial Strategy, 2024) – the requirement that these funds be accessed only through competitive applications poses a challenge for long-term planning. However, the numerous trusts that have benefited from these funds since their inception highlight a significant opportunity for enhanced collaboration. By effectively disseminating the lessons learnt from both the application process and the implementation of projects, insights can be used across all trusts, thereby maximising the potential for collective success. In addition, participants seemed to blend funds for decarbonisation with funds for backlog maintenance, as an increasing portion of capital budgets has been redirected to cover day-to-day expenses (The King’s Fund, 2024), and investments in maintenance are much lower than the estimated total cost of the backlog, creating potential long-term risks for patients, visitors and staff (Pantzartzis et al., 2019). Therefore, despite funds made available in 2019 in the Health Infrastructure Plan to improve health infrastructure, participants considered available funds only able to tackle minor issues. In addition, despite the recommendation of the “Capital investment and property business case approval guidance for NHS trusts and foundation trusts” effectively (NHS England, 2023a), according to the participants, the lack of funds forces NHS trusts to develop business cases that solely account for the initial capital, which affects their ability to maintain the asset appropriately, does not allow EFM professionals to consider resource-related issues and show the benefits of the costs that could be discounted because of long-term savings. A long-term financial strategy that recognises the evolving role of hospitals in the transition from hospital-cantered care to community-based care (Department of Health and Social Care, 2024) and the needs for climate resilience would enable EFM professionals to formulate estate management strategies able to meet future requirements and include options for repurposing or decommissioning buildings that can no longer meet changing demands due to external factors or when the obsolescence gap is too large to bridge through refurbishment. Due to the significant challenges posed by climate change, it is crucial to support innovation by simplifying and shortening the procurement process. This is particularly important for trusts that have exceeded their budget and must follow a double-lock or triple-lock sign-off process for revenue investments (Healthcare Financial Management Association, 2022). In addition, enhancing flexibility in contracts and agreements is necessary, as current regulations restrict trusts from entering into power purchase agreements or energy performance contracts. This limitation hinders the implementation of strategies aimed at offsetting carbon emissions, such as solar farming. Solar farms could be directly connected to the hospital’s electrical infrastructure, providing a sustainable energy source for NHS trusts.

The research participants expressed a disconnection between hospital leadership and EFM. According to Von Behr and Minshall (2022), this is because estate directors do not serve on every trust board, which leads to varying levels of autonomy and support for EFM. Also, in line with Von Behr and Minshall (2022), the fragmentation of the health-care system was seen as a barrier. However, suggestions were made that this could have been addressed with a shift from hospital to system leadership. Furthermore, there was widespread dissatisfaction that funding is prioritised for clinical services over estates and facilities, stemming from a lack of understanding that the estate cannot accommodate the demands of evolving clinical services without investment in physical assets, as also reported by Von Behr and Minshall (2022) and Rodriguez-Labajos et al. (2017). However, long-term clinical strategies were also viewed as an opportunity to change the approach and introduce long-term planning for the estate. To achieve this, EFM and sustainability teams need better integration into the leadership structure of the hospitals to drive the shift from a short-term planning approach, which focuses on decreasing expenditures or minimising costs, to a future-based planning approach. This is consistent with the recommendations made by Sarpin et al. (2016) and Elmualim et al. (2008) to achieve sustainability in EFM, as well as the recommendation from Amos et al. (2021), who recognised the importance of health-care leaders valuing the role of EFM in health-care delivery rather than viewing it solely as a cost centre. However, EFM professionals working in hospitals need to bridge the cultural differences between the technical and clinical staff to make the prioritise for the estate and their implication for the clinical services better understood by shifting towards a sustainable EFM practice that integrates social, environmental and economic aspects through a culturally embedded understanding (Galamba and Nielsen, 2016). Finally, enhancing the skills of hospital EFM professionals is crucial to face the growing influence of technology in the industry, which is aligned with Finch and Clements‐Croome’s (1997) conclusion that future facilities managers need to be technically qualified and understand intelligent building complexities.

EFM professionals are vital in advancing sustainability and climate resilience throughout the entire life cycle of the hospital estate. However, they need new approaches to maintain and refurbish hospitals throughout their life cycle to achieve net-zero and address changes in the external climate and the fast-paced changes happening in health-care delivery, without being biased by existing barriers. Future-based approaches to estate management, such as backcasting, that recognise the role of hospitals within a future-oriented care delivery system and the future demand of climate change, can allow EFM professionals to investigate potential intervention pathways without being constrained by the biases created by existing barriers or organisational memory. However, the current estate’s unsustainability, complexity and age present significant challenges to retrofitting and upgrading, particularly in achieving net-zero emissions and improving climate resilience. To support this process, the NHS should provide technical guidance on decarbonising and achieving climate resilience within the existing estate and clear and relatable metrics to help trusts define SMART targets and associated KPIs. In addition, a long-term financial strategy recognising the shift from hospital-centred to community-based care and climate resilience needs will help EFM professionals develop estate management strategies that address future demands. However, this also necessitates a transformation in funding, procurement and contractual strategies as the current length complexity and lack of flexibility hinder innovation. At the trust level, a thorough assessment of the existing estate is essential for implementing effective upgrading strategies for mitigation and adaptation. This needs to be supported by the development of digital estate models, which can enhance decision-making in health-care asset management and BEMSs, which can support EFM professionals in identifying areas of inefficiency and implementing targeted energy-saving measures. In addition, monitoring the existing estate with sensors can identify vulnerabilities and inform a clear BCP, thereby improving the estate’s resilience. In addition, changing the leadership culture within trusts to prioritise sustainability and climate resilience is crucial for facilitating transformation. This shift necessitates EFM professionals in the NHS to adopt a sustainable facilities management approach that incorporates social, environmental and economic aspects and integration of the EFM and sustainability teams in the leadership structure, as they represent the group of stakeholders in the organisation with technical knowledge and an understanding of the clinical needs. Therefore, they can bridge the cultural differences to help others understand the estate’s priorities and their implications for clinical services.

This study is based on insights from two workshops conducted with a single NHS trust. While it may not capture the full range of barriers and opportunities hospitals encounter to develop a sustainable and climate-resilient estate, it offers valuable perspectives. The participants are experienced experts in their respective fields, contributing diverse knowledge and experiences that foster engaging and meaningful discussions. Therefore, further research is needed to gather the views of other stakeholder groups involved in hospital asset management. In addition, more research is required to understand the connection between climate vulnerabilities and adaptation and mitigation strategies to enhance climate resilience.

This work forms part of a research fellowship funded by the Health Foundation’s grant to The Healthcare Improvement Studies Institute at the University of Cambridge. This study was approved by the Anglia Ruskin University Research Ethics Committee (approval no. ETH2223-5645) on April 23, 2023.